APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your application to ensure faster processing.

Transcription

1 State of Florida Department of Business and Professional Regulation Board of Landscape Architecture Application for Licensure of a Business Entity: Certificate of Authorization Form # DBPR LA 2 1 of 6 APPLICATION CHECKLIST - IMPORTANT - Submit all items on the checklist below with your application to ensure faster processing. TRANSACTION Certificate of Authorization APPLICATION REQUIREMENTS Complete all sections of this application. Submit the $455 fee (make check payable to the Department of Business and Professional Regulation). Attach any applicable additional documentation (i.e. additional officers or registered landscape architects, etc.) Please mail your completed application, documentation and required fee(s) to: Department of Business and Professional Regulation 2601 Blair Stone Road Tallahassee, FL

2 State of Florida Department of Business and Professional Regulation Board of Landscape Architecture Application for Licensure of a Business Entity: Certificate of Authorization Form # DBPR LA 2 2 of 6 If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at For fees additional information see the instructions at the end of this application. Section I Applicant Business Entity Qualifier Information QUALIFIER PERSONAL INFORMATION (application MUST be completed and signed by qualifier) Name DBPR License # City State Zip Phone # Position Title (Qualifier MUST be a principal officer see Instructions for details) Section II Applicant Business Entity Information ORGANIZATION INFORMATION Federal Employer ID Number and/or Social Security Number* Organization/Applicant Name Doing Business As (D/B/A) Name Ownership: Corporation Partnership LLC Non-Profit Other: Street or P.O. Box MAILING ADDRESS City State Zip Code (+4 optional) County (if Florida address) Contact Name Primary Phone Number Street Country CONTACT INFORMATION Primary BUSINESS LOCATION ADDRESS City State Zip Code (+4 optional) County (if Florida address) Country *Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance, Social Security numbers are mandatory pursuant to Title 42 United States Code, Section 653, 654, and 666(a); and Sections (9), , and , Florida Statutes. Social Security numbers must be recorded on all professional and occupational license applications and will be used to allow efficient screening of applicants and licensees by Title IV-D Child Support Agency to assure compliance with child support obligations.

3 Section II Applicant Business Entity Information - continued ADDITIONAL CONTACT INFORMATION (OPTIONAL) Alternate Phone Number Fax Number 3 of 6 Alternate OFFICER(S)/PARTNER(S) Identify each officer/partner of the applicant business entity who is a registered landscape architect in the state of Florida. Do not list officers or partners who are not registered landscape architects (attach additional pages as necessary): 1. Name DBPR License # Principal Officer? City State Zip 2. Name DBPR License # Principal Officer? City State Zip 3. Name DBPR License # Principal Officer? City State Zip Section II Applicant Business Entity Information - continued BUSINESS INCEPTION/FOUNDING DATES Date company was registered/filed with the FL Secretary of State (if pending, please acknowledge) (MM/DD/YY): Has the company solicited and/or offered landscape architecture services in the State of Florida prior to being licensed by the Florida board? No Yes - If yes, list the last three projects with start and end dates wherein the company solicited for or provided such services: 1. Name of Client Project Type Client City State Zip Start Date End Date 2. Name of Client Project Type Client City State Zip Start Date End Date 3. Name of Client Project Type Client City State Zip Start Date End Date

4 Section III (a) Background Questions BACKGROUND QUESTIONS 1. Has this company ever been a defendant in civil or criminal litigation? No Yes - If yes, complete Section III (b) of this application as appropriate. 2. Has disciplinary action ever been sanctioned by a State regulatory board against the company? No Yes - If yes, complete Section III (c) of this application. Please note: you will be notified if the Board requires additional documentation. 4 of 6 Section III (b) Explanation(s) for Background Question 1 Offense County State Penalty/Disposition Date of Offense (MM/DD/YYYY) / / Description Have all sanctions been satisfied? Offense County State Penalty/Disposition Date of Offense (MM/DD/YYYY) / / Description Have all sanctions been satisfied? Offense County State Penalty/Disposition Date of Offense (MM/DD/YYYY) / / Description Have all sanctions been satisfied?

5 Section III (c) General Explanation for Background Question 2 Please provide details of any disciplinary action(s) against the company by a State regulatory board including, but not limited to, date, description, state, disposition/discipline, and status of compliance. 5 of 6 Section IV Affirmation By Written Declaration AFFIRMATION BY WRITTEN DECLARATION I certify that I am empowered to execute this application as required by Section , Florida Statutes. I understand that my signature on this written declaration has the same legal effect as an oath or affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are true. I understand that falsification of any material information on this application may result in criminal penalty or administrative action, including a fine, suspension or revocation of the license. Signature: Date: Print Name:

6 Section V - Instructions If you have any questions or need assistance in completing this application, please contact the Department of Business and Professional Regulation, Customer Contact Center, at of 6 1. General Requirements for Certificate of Authorization a. The applicant business entity s qualifier must complete all sections of the application. The qualifier must be a principal officer of the applicant business entity and a Florida registered landscape architect (see Section b. below). b. At least one of the principal officers (see definition below) of the corporation, or partners of the partnership must be a registered landscape architect. a. The company must be listed with the Department of State. Accuracy of business information may be checked on the Florida Division of Corporations website b. A principal officer is defined as the President, Vice President, Secretary or Treasurer of a company; or c. Any other officer who has management responsibilities in the corporation, as documented by the corporate charter or by-laws. ii. All personnel of the corporation or partnership who act in its behalf as landscape iii. architects must be registered landscape architects. One or more of the officers, one or more of the directors, one or more of the owners of a corporation, or one or more of the partners of a partnership must be a registered landscape architect. c. Additional Qualifier Requirements i. If the applicant business entity is a limited liability company, the qualifier must be a managing member. The company must also file with the board. ii. If the applicant business entity is a non-profit corporation, the qualifier must provide bylaws which clearly identify his or her duties and responsibilities. 2. Application Instructions (by section) a. Section I i. Provide the name and address information for the Florida Licensed Landscape Architect that will qualify the business. ii. The position title must be: a. If a Corporation a principal officer which is defined as the President, Vice President, Secretary or Treasurer or b. If a Partnership a Partner c. If a not for profit Organization the by-laws must be provided that clearly identify the duties and responsibilities of the qualifier. b. Sections II III (c) i. Fill out each section completely. ii. Accuracy of business information may be checked on the Florida Division of Corporations website Provide business information as it is registered with the Florida Division of Corporations. ii. iii. For Sections III (b) and III (c), provide as much detail as possible. For Section III (b), if necessary, submit supporting legal documentation with this application. c. Section IV i. Applicant must sign the affirmation by written declaration.